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SUNNY /StF.f <br />O� R� <br />� n <br />V Z <br />k t <br />S'F D97� FEOP�� SbF <br />a° <br />CITY op SUN A <br />STATE OF FLORIDA ) <br />COUNTY OF ) <br />ANTI - KICKBACK <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, FL 33160 <br />Telephone: (305) 947-0606 Fax (305)949 -3113 <br />ANTI - KICKBACK AFFIDAVIT <br />I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid <br />will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a <br />commission, kickback, reward or gift, directly or indirectly by me or any member of my firm or <br />by an officer of the corporation. <br />a <br />Title: <br />The foregoing instrument was acknowledged before me this day of <br />, 20 , by [name <br />of person], as [type of authority], for <br />[name of party on behalf of whom instrument was <br />executed]. <br />AFFIX NOTARY STAMP HERE: <br />Notary Public — State of Florida <br />Print or Type Commissioned Name <br />Personally Known OR Produced Identification <br />Type of Identification Produced <br />7 of 7 <br />DECEMBER 28, 2010 <br />